CULTURALLY COMPETENT CARE FOR LGBTQ+ PATIENTS

Even though social acceptance of LGBTQ+ individuals has been increasing, LGBTQ+ patients continue to face barriers to culturally competent care, including stigma and discrimination. For these patients, access to healthcare that is unbiased and culturally affirming remains a challenge in most parts of the United States (Butler et al., 2016).

It is not uncommon for a person who identifies as lesbian, gay, bisexual, transgender, or questioning/queer (LGBTQ) to have had negative experiences in the healthcare environment due to discrimination and/or stigmatization based on their sexual orientation and/or gender identity. Such encounters may occur due to cultural bias or a lack of awareness and understanding by the provider of the healthcare needs and goals of such individuals.

For example:

• A gay man might be screened for HIV before being assessed for actual risk.
• A transgender man may be denied a mammogram because they transitioned from female to male.
• A lesbian visiting a new primary care provider might be asked if they would like a mental health referral to explore “abnormal” sexual feelings.
• A gender fluid person may not know how to respond to a healthcare form that only provides the options of male or female gender identity.

These sorts of negative encounters immediately affect the patient’s trust of the healthcare system and marginalize their needs. Continuing stigma makes many patients reluctant to reveal their sexual orientation or gender identity to healthcare providers even though this information can be important to receiving individualized care.

From a historical perspective, it was not until 1973 that the American Psychological Association declared that homosexuality (now considered a marginalizing term) was not a mental illness (McHenry, 2022). This was a major milestone in the movement toward cultural awareness and in the fight for equal rights for people who identify as lesbian, gay, or bisexual. Similarly, being transgender was listed as “gender identity disorder” until 2013, when the DSM-5 changed it to “gender dysphoria,” a more patient-centric term (Byne et al., 2020).

Over the past 20 years, the healthcare community has started to recognize and research the unique needs of these groups. One of the most significant reports includes the 2011 Institute of Medicine report titled “The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding.” This document outlined a research agenda for the future. The report also placed a focus on the needs of LGBT patients and described the uniqueness for each of the LGBT groups (IOM, 2011). Similarly, Healthy People 2030 includes a goal to improve the well-being, safety, and health of the LGBT patient population (ODPHP, n.d.).

Even though social acceptance has been increasing since that time and laws and policies are changing, LGBTQ+ individuals continue to face barriers, stigma, bias, and discrimination. Access to healthcare that is unbiased and culturally affirming remains a challenge in most parts of the United States.

People within the LGBTQ+ population are extraordinarily diverse, representing every social class and ethnicity in every geographical area and every profession (HRC, 2020). Healthcare professionals who practice cultural sensitivity in working with LGBTQ+ patients can have a positive impact and increase trust as they continue to understand the individual needs of their patients.

Terms and Definitions

To better understand the LGBTQ+ population and their unique health concerns, it is important to define and clarify some basic concepts of gender identity and sexual orientation. Terms and definitions are ever-evolving, and clinicians must update their knowledge regularly to provide effective and respectful care for all patients. It is also important that clinicians have the comfort and sensitivity to ask their patients how they would like to be addressed in terms of identifiers of gender identity and sexual orientation in a respectful, honest, and open-minded manner.

Terminology described in this course is taken from recognized sources at the time the course was written. These terms may not reflect every individual’s personal preference, may become outdated (even as they are mentioned in current clinical references), and may not reflect all local and regional variations.

• Anatomical sex: The presence of certain female or male biologic anatomy (including genitals, chromosomes, hormones, etc.); also referred to as assigned sex at birth (ASAB)
• Asexual (A): People with no or little sexual attraction to other people
• Bisexual (B): Men or women who are sexually attracted to people who are the same as and different than their own gender
• Cisgender: People whose gender identity aligns with the sex they were assigned at birth, i.e., the opposite of transgender or gender diverse
• Gay (G): A person who is attracted to someone of the same gender; historically, the term referred to men who are attracted to men, but it may also be used by women to refer to themselves
• Gender expression: The way a person presents their gender in society, through social roles, clothing, make-up, mannerisms, etc.
• Gender identity: A person’s internal sense of being a male/man, female/woman, both, neither, or another gender
• Genderfluid or genderqueer (also called nonbinary): People who do not strictly identify as male or female; a mix of male and female (genderqueer/genderfluid); neither male nor female (nonbinary); or no gender at all
• Intersex (I): People with an indeterminate mix of primary and secondary sex characteristics, such as a person born appearing to be female “outside” who has mostly male anatomy “inside,” a person born with genitals that are a mix of male and female types (a female born with a large clitoris or without a vaginal opening, or a male born with a small penis or a divided scrotum that has formed like labia); may identify as either cisgender or gender diverse
• Lesbian (L): Women who are attracted to women
• MSM: Men who have sex with men
• Queer: An umbrella term for all who are not heterosexual or who are not 100% clear of their sexual orientation and/or gender identity
• Questioning (Q): A person who is in the process of discovery and exploration of their sexual orientation, gender identity, or gender expression
• Sexual orientation: How a person identifies their sexuality, including who they are physically and emotionally attracted to and with whom they choose to have sex; a person may not have a sexual attraction to others (asexual)
• Transgender (T): People with gender identities that do not align with their assigned sex at birth; some transgender individuals may alter their physical appearance and often undergo hormonal therapy or surgeries to affirm their gender identity. However, medical intervention is not required for a person to identify as transgender. Some transgender people do not undergo the medical transition process for a variety of reasons, including cost or other health concerns. Gender identity terms that may be used by transgender people to describe themselves include:
• Demiboy: A person who feels their gender identity is partially male, regardless of assigned sex at birth
• Demigirl: A person who feels their gender identity is partially female, regardless of assigned sex at birth
• Transgender female/woman, trans woman: A transgender person who was assigned male at birth (AMAB) but who identifies as female; formerly referred to as male-to-female (MTF)
• Transgender male/man, trans man: A transgender person who was assigned female at birth (AFAB) but who identifies as male; formerly referred to as female-to-male (FTM)
• WSW: Women who have sex with women
  (AECF, 2021; APA, 2022; PFLAG, 2022)

Terms and Concepts That May Be Marginalizing

Terms that marginalize and stigmatize people who are LGBTQ+ are still common. Also, some words previously used and accepted in the medical community may no longer be in common usage or considered acceptable/respectful today. Examples include:

• Homosexual
• Sexual preference
• Transvestite
• Male-to-female (MTF) transgender
• Female-to-male (FTM) transgender
  (PFLAG, 2022; GLAAD, n.d.)

Examples of concepts that may contribute to societal stigmas for LGBTQ+ patients include:

• Heterosexism: The general presumption that everyone is straight or the belief that heterosexuality is a superior expression of sexuality
• Homophobia: Negative attitudes and feelings toward people with nonheterosexual sexualities; may include discomfort with expressions of sexuality that do not conform to heterosexual norms
• Internalized oppression: The belief that straight and cisgender people are “normal” or better than LGBTQ+ people, as well as the often-unconscious belief that negative stereotypes about LGBTQ+ people are true
• Transphobia: Negative attitudes and feelings toward transgender people or discomfort with people whose gender identity and/or gender expression do not align with traditionally accepted gender roles
  (PFLAG, 2022; Ni, 2020)

Sexual Orientation, Gender Identity, and Gender Expression

Sexual orientation, gender identity, and gender expression are separate parts of a person’s identity. Sexual orientation refers to a person’s sexual attraction and sexuality. Gender identity refers to a person’s innate sense of their own gender. Gender expression refers to the outward expression of one’s gender. All of these terms fall along a spectrum, and a person can identify with more than one sexual or gender identity.

The terms lesbian, gay, and bisexual describe an individual’s sexual orientation, attraction, or behavior and reflect the fact that sexuality is not exclusively heterosexual. In contrast, transgender people are defined according to their gender identity and presentation. This group is composed of individuals whose gender identity differs from the sex originally assigned to them at birth or whose gender expression varies significantly from what is traditional for that sex (i.e., people identified as male at birth who subsequently identify as female and people identified as female at birth who later identify as male).

Transgender individuals (and many others) may also reject traditional concepts of gender as being strictly binary in terms of the male-female dichotomy. The population is diverse in gender identity, expression, and sexual orientation. Transgender people can be any sexual orientation. Some lesbians, gay men, and bisexuals may be transgender (APA, 2022).

The gender-binary system is also important to understand in the context of the LGBTQ+ population. This system is based on the idea that society categorizes people as falling into one of two categories (man/woman, male/female, masculine/feminine), not recognizing gender is a spectrum. Individuals who identify as nonbinary or genderfluid often identify as being somewhere in the middle of this spectrum and may use gender-neutral pronouns such as “they/them/theirs.” Therefore, it is important to address the question of pronouns with patients in each healthcare encounter.